Fraud Investigation Manager manages the operations of the fraud investigations department. Develops policies and procedures to prevent fraud activities and to recover any incurred losses. Being a Fraud Investigation Manager identifies the weakness of current control process and recommends enhancements. Collaborates investigation with appropriate business partners and local, state and federal authorities. Additionally, Fraud Investigation Manager requires a bachelor's degree. Typically reports to a head of a unit/department. The Fraud Investigation Manager typically manages through subordinate managers and professionals in larger groups of moderate complexity. Provides input to strategic decisions that affect the functional area of responsibility. May give input into developing the budget. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. To be a Fraud Investigation Manager typically requires 3+ years of managerial experience. (Copyright 2024 Salary.com)
Description
JOB SUMMARY
This job is responsible for development and implementation of strategic audit plans utilizing numerous inputs including contracts, industry trends and revenue maximization schemes.
The incumbent will also work with other audit team members and external vendors to develop specific auditing techniques to identify overbilling and potential recoveries / savings.
Will be called upon as a subject matter expert for investigations providing guidance and mentoring to investigative team.
Must be able to testify in a court of law, prepare cases for referral to various federal, state and local law enforcement entities and work with those agencies through closure of the case.
Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.
ESSENTIAL RESPONSIBILITIES
Communicate findings to company management of various areas including provider relations, reimbursement etc.
Calculate overpayments in established fraud, waste or abuse cases. Identify all fraudulent activity included in the case, determine what lines of business were involved in the fraudulent activity, and measure overpayment by means of sampling or complete review.
Negotiate settlements with providers.
EDUCATION
Required
Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field
Substitutions
6 years of related and progressive experience in lieu of Bachelor's degree
Preferred
Master's degree in Fraud, Forensics Accounting, Business or related field
EXPERIENCE
Required
Preferred
LICENSES or CERTIFICATIONS
Required
None
Preferred
SKILLS
Language (Other than English) :
None
Travel Requirement : 0% - 25%
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Frequently
Travel regularly from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products / services (sales employees)
Never
Physical work site required
Lifting : up to 10 pounds
Constantly
Lifting : 10 to 25 pounds
Occasionally
Lifting : 25 to 50 pounds
Rarely
Pay Range Minimum : $78,900.00
$78,900.00
Pay Range Maximum : $146,000.00
$146,000.00
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation / gender identity or any other category protected by applicable federal, state or local law.
Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation / gender identity, protected veteran status or disability.
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Equal Opportunity Employer Minorities / Women / Protected Veterans / Disabled / Sexual Orientation / Gender Identity ()
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Last updated : 2024-05-10